Discontinuing antidepressants without withdrawal symptoms – is that possible?

It was the worst time in Mark Horrowitz’s life so far. He even seriously considered taking his own life for the first time. The Australian was in the process of coming off the antidepressants he was taking for his anxiety and depression a few years ago. But by the time he came off, his condition was worse than it was before he started taking the antidepressants. “During that time, I could barely sleep more than a few hours a night and was so anxious I could hardly think straight,” says Horrowitz. He also suffered from dizziness and difficulty concentrating. “It had an incredible impact on my life and I had to take a break from work.” As a result, he went back to the medication.

Not all patients experience symptoms when weaning. Still others have symptoms, but they aren’t that bad. But a significant proportion develop anxiety, emotional lability, mood swings, irritability, dizziness, tremors, and fatigue. How many patients are ultimately affected is not entirely clear. Some sources estimate the number of those affected at one third. Mark Horrowitz even assumes more than half. And he knows what he’s talking about. Because the topic of withdrawal symptoms affects him not only personally, but also professionally. As a psychiatrist at University College London, the Australian researches the long-neglected topic. With his work, he wants to prevent other patients from going through what he went through. After all, the symptoms can plague patients for months, much longer than the week or two long thought to be. As a result, many take the medication again that they actually wanted to stop.

Withdrawal symptoms versus symptoms of depression

Unfortunately, there are still doctors and therapists who believe that problems with weaning are a sign of the return of depression, says psychiatrist Gerhard Gründer from the Central Institute for Mental Health in Mannheim. “But that makes it too easy for yourself.” Especially since you can usually distinguish withdrawal symptoms from returning depression symptoms. Discontinuation or withdrawal symptoms occur very quickly after the last tablet, with some drugs such as venlafaxine even after a few days. “Recurring depression, on the other hand, does not occur so suddenly,” says Gründer. In contrast to the primarily psychological symptoms of recurring depression, the withdrawal symptoms are also very physical. They affect all possible organ systems. Sensory symptoms such as blurred vision or tinnitus can occur. “Or they come from the gastrointestinal tract and manifest themselves in nausea and vomiting, diarrhea and constipation.”

Withdrawal symptoms from stopping antidepressants occur because the brain becomes accustomed to their presence. When antidepressants are stopped, the brain “misses” the drug and expresses this through withdrawal symptoms. Currently, the recommendation is often to “taper off” the dose of the medication over two to four weeks. The dose is reduced in constant steps until you finally stop taking the drug. That’s what Mark Horrowitz tried to do. Today he is convinced that you have to taper off antidepressants much more slowly. In fact, there are studies that show that tapering off according to the “standard recipe” is often unsuccessful.

Quickly at first, then reduce more slowly

Horrowitz bases his argument on the biology of the brain. He cites the so-called selective serotonin reuptake inhibitors as an example. They are often prescribed and are intended to prevent the nerve cells in the brain from absorbing the released serotonin too quickly – a messenger substance that is important for communication between nerve cells. This increases the concentration of serotonin in the brain. If a patient now discontinues the medication, the intention of the phasing out is to give the brain time to get used to the reduced dose of active substance and thus reduce the withdrawal symptoms. However, according to Horrowitz, many doctors believe that if you reduce the dose by half, the effect in the brain would also be reduced by half. However, according to studies, the effect on the gray matter diminishes more and more with each dose reduction, leading to worsening withdrawal symptoms.

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Mark Horrowitz therefore recommends in a scientific article in the journal “Lancet Psychiatry” to reduce the antidepressants a little more quickly at first and then more and more slowly. So instead of reducing the antidepressant citalopram from the usual daily dose of 20 mg constantly in steps of five, first to 15, then 10 mg, etc., it should be reduced to 9.1 mg in the first step. Then you should go down to 5.4, then to 3.4, etc. Initial studies suggest that such a procedure can help people who had problems with the conventional method to wean themselves.

Basic recommendations are problematic

“It is important to slowly wean off antidepressants,” confirms Gerhard Gründer. He wrote a book on the subject two years ago. He also says: You should reduce the dose more quickly at the beginning. In the further sections, the tablets would then be reduced in ever smaller steps. “It goes so far that patients open the capsules and count the beads inside.”

Critics find such an extremely slow phasing out as a basic recommendation problematic. Many patients have no symptoms and then have to endure months with the medication. “Of course there are many patients who can stop taking antidepressants more quickly without any problems,” says Gerhard Gründer. “But since we can’t predict who will have problems when weaning, the tapering should be done very slowly over months.” Of course, you could try it faster first. You can try stopping the pills in six weeks or less. “But if withdrawal symptoms occur, you should taper off more slowly in a second attempt.”

Mark Horrowitz, meanwhile, is taking his time gradually tapering off his antidepressant dose and tapering it off on his own schedule. His conclusion: “It works very well for me.”

Book data: Gerhard Gründer: “Discontinue psychotropic drugs? Why, when and how?”; Urban & Fischer Verlag/Elsevier GmbH; 128 pages, 29 euros.